Not at Peace

Mr. G was a hospice patient. I'm a palliative care doctor. It was Friday evening. Dr. Gupta, Mr. G's physician, was out of town for the weekend, and I was covering. I was supposed to be meeting friends for dinner but had received a page that afternoon. Elsa, the unit clerk, usually greets me with a cheery "Hi, Dr. B" when I call in, but this time she said, "Oh, I'll get Sheila right away." Something wasn't right.

Sheila was the new charge nurse. I had not worked with her for very long, and we were both frustrated as we went over the case—I because of the rapid staff turnover that seemed to be a continual issue at the hospice, and she at having to deal with the weekend cross-cover doc. She explained to me that Mr. G wanted his gastrostomy and tracheotomy tubes pulled. Mr. G was eighty-three years old and had been at the hospice for a few days, transferred from the hospital where he'd undergone bypass surgery a few months ago. He'd gotten the G-tube and the trach when he developed renal failure, sepsis, and pneumonia after the operation, and now he wanted them out. In fact, he said he had "never really wanted them in the first place." Apparently, the physicians caring for him had initially conveyed to the family that he would improve, but over the past few months he was "dwindling" and quite miserable. However, when Dr. Gupta signed out that morning, he told me, "I don't think Mr. G's family will want to do anything over the weekend, and we can sort it out more when I return. It's been very difficult for everyone involved." I could tell that he was including himself. Dr. Gupta had worked in hospice for twenty years and I valued his opinions.

When I arrived, much later than I had hoped and not until after Sheila had already left for the day, I entered the room to find two daughters and a son, all bleary eyed. A man with a trach and PEG, but otherwise looking relatively well, was lying in the bed. His eyes were piercing blue and conveyed a sense of urgency bordering on angst.

I introduced myself and explained that I had been told by Sheila and Dr. Gupta what had happened and wanted to discuss what should happen next. It was clear from the outset that the family had done all the "discussing" they wanted to do and were ready for action.

I began to speak to Mr. G. Since he could not talk with his trach, I got out the pad next to his bed and gave it to him. He pushed it away. His daughter said, "He's tired of it." I told him I just needed to confirm with him that taking out the tubes was what he wanted. He nodded in agreement. The family looked at me expectantly.

I knew what I was supposed to do next: write an order for morphine, and then the order to remove the trach and cap the G-tube. I couldn't tell for sure what would happen when the trach was removed. Mr. G seemed to be breathing comfortably on four liters of oxygen, but he wanted that discontinued as well.

Decisions of this sort usually didn't bother me, but for some reason, something did not seem right with this one. I excused myself and paged Sheila. I asked her for more details. She told me that Mr. G's family was having a difficult time accepting his wishes, but that he himself had been clear and consistent throughout; he did not want to live a life in which he could neither eat nor speak. That afternoon she had had a long discussion with Mr. G and his children, and they had reached a consensus to pull the tubes.

I re-entered the room. I explained that I had spoken to Sheila, that we would move forward and remove the tubes, that we would provide morphine for shortness of breath, and that he would...